CARE HOME ADULTS 18-65
The Evergreens Hemlington Village Road Middlesbrough TS8 9DE Lead Inspector
Val Daly Unannounced Inspection 31st January 2006 09:30 The Evergreens DS0000000055.V280518.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Evergreens DS0000000055.V280518.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Evergreens DS0000000055.V280518.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service The Evergreens Address Hemlington Village Road Middlesbrough TS8 9DE Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01642 599744 01642 595744 Salco Homes Limited Mr Anthony Griffiths Care Home 18 Category(ies) of Learning disability (18), Physical disability (15) registration, with number of places The Evergreens DS0000000055.V280518.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 13th June 2005 Brief Description of the Service: The Evergreens is registered with the Commission for Social Care Inspection under the Care Standards Act 2000 as a care home to provide care and accommodation for eighteen adults who have a learning disability. The home is compromised of three single storey dwellings, Juniper having nine places, Redwood having three places and Aspen having six places. The care home is situated in a secluded site set back from a main link road and close to a popular public house and has views over undeveloped grassland. The Evergreens DS0000000055.V280518.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection commenced at 10am and lasted for three hours. The manager and staff were spoken to and residents were observed during the inspection. Numerous records including care plans, risk assessments, menus, complaints, staff training and policies and procedures were examined. A partial tour of the home was carried out. Three residents were spoken to in general and staff interaction with them was observed during the inspection. A partial tour of the home was carried out. What the service does well: What has improved since the last inspection?
The manager has reviewed and changed the care planning documentation. It is now more comprehensive, detailed, user friendly and shows relative and resident involvement. Menus showed that a variety of food is offered to the residents with input from them as to their likes and dislikes. Some refurbishment has taken place; in Redwood a new suite has been purchased for the lounge along with a new carpet and the tiles have been regrouted in the shower room. Six of the bedrooms have been refurbished, some by relatives with residents being involved. In Aspen a new suite has been purchased for the lounge and a new carpet is in the office. In Juniper a new suite has been purchased for the lounge along with a new carpet in the corridor. The Evergreens DS0000000055.V280518.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Evergreens DS0000000055.V280518.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Evergreens DS0000000055.V280518.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These five standards were not assessed at this inspection. However at the previous inspection resident assessments were not clear. The manager has put new documentation in place and individual needs and aspirations are included. EVIDENCE: The Evergreens DS0000000055.V280518.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 Residents are supported to take risks within a risk management framework. This helps to ensure they remain safe and that their independence is promoted. EVIDENCE: Three care plans were examined and risk assessments were in place where required. The risk assessments were comprehensive and detailed and include; what will be assessed, person responsible for monitoring the risk assessment, persons involved in completing the documentation, who will be directly at risk, will any other persons be affected, are there any resident’s individual characteristics which may affect risk exposure, are there any environmental factors which may affect risk exposure, any other factors, potential benefits, date completed and date for review. The Evergreens DS0000000055.V280518.R01.S.doc Version 5.1 Page 10 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15, 16 & 17 Good contact is maintained between the residents and their relatives and the opportunity is available for residents to spend time with their families outside of the home. The food is of good quality and sufficient to meet the needs of the residents. EVIDENCE: Many of the residents have regular contact with friends and family. As many of the residents attend Day Centres during the week visits or outings usually take place in the evenings and at weekends. Care plans showed that residents and relatives are involved with them and resident’s rights and responsibilities are recognised. Menus showed that a variety of food is offered to the residents with input from them as to their likes and dislikes. The main meal is at tea- time to fit in with the resident’s lifestyles. The Evergreens DS0000000055.V280518.R01.S.doc Version 5.1 Page 11 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 & 19 Residents receive support from staff to ensure that their personal, physical and emotional needs are met. EVIDENCE: A health action plan is completed with the resident. This covers all aspects of health. Residents attend the local General Practitioner when required with assistance from staff or relatives. They are also seen by their Consultant and have Care Programme Approach meetings six monthly or annually. Epilepsy nurses also visit individual residents six weekly and protocols are changed as needed. The Evergreens DS0000000055.V280518.R01.S.doc Version 5.1 Page 12 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 The home has a complaints system, which residents can use if they are unhappy. There are satisfactory procedures in place, which protect the residents from abuse. EVIDENCE: The home has a written complaints policy and procedure in place. There is also a procedure in picture format for those residents who need it. There have been no complaints made to the home since January 2004. The home has an Adult Protection policy and procedure in place. Staff files examined showed that training in ‘No Secrets has been given. A member of staff confirmed the training had taken place. The Evergreens DS0000000055.V280518.R01.S.doc Version 5.1 Page 13 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These seven standards were not assessed at this inspection. However at the last inspection some refurbishment was identified as being needed, and this has since been carried out. EVIDENCE: The Evergreens DS0000000055.V280518.R01.S.doc Version 5.1 Page 14 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 & 35 There is sufficient staff available to meet the current needs of residents presently living in the home but more staff need to complete their training so that they can develop the skills they need to support the residents. EVIDENCE: Since the previous inspection the manager has identified the training needs of the staff. Training in First Aid, Fire Safety and distance learning in the Safe Handling of Medication has recently taken place. There now needs to be a staff training and development plan in place. More carers are required to undertake and complete NVQ to ensure that the home meets the required 50 of carers with the qualification. At the time of the inspection the manager had met with a training organisation for more carers to undertake NVQ training. There was evidence to show that staff receives formal supervision every eight weeks. The Evergreens DS0000000055.V280518.R01.S.doc Version 5.1 Page 15 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 & 39 Arrangements to make sure that the service continues to improve and to ensure that resident’s views are taken into consideration have begun to be introduced. EVIDENCE: The manager has settled into his role and has made positive changes both to the way in which the care is delivered and to residents and making the care documentation more comprehensive and user friendly. At the time of the inspection the manager was in the process of sending out questionnaires to families, residents and staff to get their views on the service provided. The manager has previously carried out a quality audit with staff. The Evergreens DS0000000055.V280518.R01.S.doc Version 5.1 Page 16 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 2 33 X 34 X 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X X 3 X 2 X X X X The Evergreens DS0000000055.V280518.R01.S.doc Version 5.1 Page 17 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA32 YA35 YA39 Good Practice Recommendations More care staff need to undertake and complete NVQ level 2 or above in care. There should be a staff training and development plan in place. A quality assurance audit for residents, relatives and staff needs to be carried out. The Evergreens DS0000000055.V280518.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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